Evaluating the Patient with a Knee Injury

American Family Physician - Volume 71, Issue 6 (March 2005) - Copyright 2005
American Academy of Family Physicians - About This Journal
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Evaluating the Patient with a Knee Injury

MARK H. EBELL M.D., M.S. 1 2

1
Athens, Georgia
2
MARK H. EBELL, M.D., M.S., is in private practice in Athens, Ga., and is associate
professor in the Department of Family Practice at Michigan State University College of
Human Medicine, East Lansing. He also is deputy editor for evidence-based medicine of
American Family Physician.

Address correspondence to Mark H. Ebell, M.D., M.S., 330 Snapfinger Dr., Athens, GA 30605 (e-mail:
ebell@msu.edu). Reprints are not available from the author.

Knee Injury

Clinical Question

What is the most appropriate evaluation for a patient with an acute knee injury?

Evidence Summary

Traditionally, physical examination maneuvers, such as the Lachman test, the pivot
shift, the anterior drawer, and the McMurray test, have been recommended for patients
with acute or subacute knee injury. A recent systematic review identified 35 studies
[1]

that used results of arthroscopic surgery as the reference standard; however, in most of
these studies, the arthroscopists were not blinded to the physical examination findings,
and most studies had other design flaws. Nevertheless, they still provide important
guidance regarding the relative accuracy of the most widely used maneuvers. Data for [1]

the physical examination are summarized in Table 1. A positive Lachman test or pivot
test is strong evidence of an existing anterior cruciate ligament (ACL) tear, and a
negative Lachman test is fairly good evidence against that injury. Although widely
used, the anterior drawer is the least helpful maneuver for diagnosing an ACL tear.
 Joint line tenderness is not very helpful at ruling in or ruling out meniscal injury, while
a positive McMurray test is most helpful for confirming the diagnosis.

TABLE 1 -- Accuracy of Specific Physical Examination Maneuvers for the Diagnosis

of Knee Injuries
Information from Jackson JL, OMalley PG, Kroenke K. Evaluation of acute knee pain in
primary care. Ann Intern Med 2003:139:57588.
Probability of specific injury if
examination maneuver is:

Maneuver Positive LR *
Negative LR *
Positive (%) Negative (%)
ACL tears
Lachman test 12.4 0.14 58 2
Anterior drawer 3.7 0.6 29 6
test
Pivot test 20.3 0.4 69 4
Meniscal injury
Joint line 1.1 0.8 11 8
tenderness
McMurray test 17.3 0.5 66 5
LR=likelihood ratio; ACL =anterior crucial ligament.
*The likelihood ratio is a measure of how well a positive test rules in disease or a negative test rules out
disease.
Given an overall likelihood of each injury of 10 percent. If clinical suspicion is higher or lower than this
10 percent pretest probability, then the probability would be correspondingly higher or lower.

Radiography also is widely used, but is unhelpful in many cases. Several clinical
decision rules have been developed to assist the physician by identifying patients who
are at very low risk of bony injury and so do not require a radiograph. The Pittsburgh
Knee Rule recommends obtaining a radiograph for patients with a recent fall or
[2]

blunt-trauma mechanism, those who are younger than 12 years or older than 50 years,
and patients who are unable to take four weight-bearing steps in the emergency
department or primary care office. In a prospective validation3 conducted by the
developers of the Pittsburgh Knee Rule, the rule was 99 percent sensitive and 60
percent specific for diagnosing acute knee injury in a convenience sample of 934
patients between six and 96 years of age. In this group, 25 percent of patients with a
positive Pittsburgh Knee Rule evaluation had a fracture, and 99.7 percent with a
negative evaluation had no fracture.
 The Ottawa Knee Rule considers five items: (1) age 55 years or older; (2) tenderness
at the head of the fibula; (3) isolated tenderness of the patella (no bone tenderness of
knee other than patella); (4) inability to flex knee to 90 degrees; and (5) inability to
bear weight for four steps both immediately and in the examination room regardless of
limping. The presence of any of these items is an indication for radiography. The
Ottawa Knee Rule has been more extensively validated in a greater variety of adult
populations than other rules, and, therefore, was recommended in a 2003 systematic
[4]

review as the preferred clinical decision rule for acute knee injury. A study that
[1] [3]

included adults and children, and a study of only children showed lower sensitivity
[5]

for the Ottawa Knee Rule; therefore these rules should not be used in pediatric
populations. The Pittsburgh Knee Rule found adequate sensitivity in a mixed
population of adults and children by ordering radiography for children younger than
12 years. [3]

The accompanying patient encounter form for patients presenting with acute knee
injury includes the four most accurate clinical examination maneuvers and guidelines
for ordering radiography based on the Ottawa Knee Rule. It also reminds physicians
always to consider performing radiography in children younger than 12 years given
the results of the Pittsburgh Knee Rules. The back side of the form illustrates the
physical examination maneuvers.
Applying the Evidence

A 38-year-old man experienced a sudden severe pain in his left knee as he was
carrying a couch up some stairs while pivoting on that leg. He initially is able to
ambulate, but later develops locking relieved by shaking his leg gently. On
examination, he has a small effusion, no erythema, nearly normal range of motion, and
slight joint line tenderness medially. There is no tenderness of the patella or head of
the fibula.

Answer. Using the Ottawa Knee rule, a radiograph is not indicated. While he has
negative results for anterior drawer, Lachman, and pivot tests for an ACL tear, he has a
positive result for the McMurray test. Although his magnetic resonance imaging is
negative for ligamentous or meniscal tear, a tear of the medial meniscus is discovered
during arthroscopic exploration.

EDITOR S NOTE: This case was the authors experience with his own knee injury.

REFERENCES

1. Jackson
JL, OMalley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med
2003:139:57588. Abstract

2. Seaberg DC, Jackson R. Clinical decision rule for knee radiographs. Am J Emerg Med 1994;12:5413.
Abstract

3. Seaberg DC, Yealy DM, Lukens T, Auble T, Mathias S. Multicenter comparison of two clinical decision
rules for the use of radiography in acute, high-risk knee injuries. Ann Emerg Med 1998:32:813. Full Text

4. Bachmann LM, Haberzeth S, Steurer J, ter Riet G. The accuracy of the Ottawa knee rule to rule out knee
fractures: a systematic review. Ann Intern Med 2004:140:1214. Abstract

5. Khine
H, Dorfman DH, Avner JR. Applicability of Ottawa knee rule for knee injury in children. Pediatr
Emerg Care 2001;17:4014. Abstract